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DISCUSSION

CO-MORBIDITIES

Co-morbidities were present in 18.7% of patients. Diabetes was the commonest (8.9%), followed by hypertension (5.4%) and CAD (2.7%).

ETIOLOGY

Acute diarrhoeal disease was the leading cause of AKI in our study accounting for 50 % of cases. This is despite an improvement in hygiene, socioeconomic and living conditions and a greater stress on rehydration therapies. This may be in part due to a lack of awareness on the part of

general practitioners, delays in correction of fluid and electrolyte losses, and late referral.18Although there seems to be a decline in AKI due to diarrhoeal disease reported from other centers,18 such a pattern was not observed here.

In our study, AKI due to ADD was most common in the 3rd decade (30.3%). Males (64.2%) were commonly affected by ADD than females. Because they are the bread winners of the family, they are used to consuming outside food.

AKIN stage distribution of ADD: Stage 1, 17(30.4%); Stage 2, 13(23.2%); Stage 3, 26 (46.4%).

Of 56 patients with AKI due to ADD, 13 (23.2%) were treated with dialysis. The remaining 43 patients (76.8%) were treated conservatively. The mortality observed during the study was 1.8%.

Jayakumar et al132 in their study from Chennai reported that ADD was the commonest cause of AKI (28.6%). The mortality was 8.7% and requirement of RRT was 66.1%.

Kaul et al129 in their study reported that 29 % cases of AKI in North India were due to diarrhoeal diseases. Mortality was 14.8% and requirement of RRT was 72.2%.

AKI following snake bite is a major problem in rural India, contributing to 21.4 % of AKI cases in our study. This is comparable to other reported series from India (13-32%).444

AKI due to snake bite also was also common in the 3rd decade (41.6%) and in males (66.6%). Males are the bread winners of the family. They indulge in agricultural work without adequate use of protective footwear. This may be reason for the above finding.

AKIN stage distribution of snake bite: Stage 1, 8(33.3%); Stage 2, 2(8.3%); Stage 3, 14 (58.3%).

Of the 24 patients with snake bite AKI, 11(45.8%) were treated with dialysis. There was no mortality observed during the study.

Athappan et al133 in their study from Madurai reported the prevalence of AKI in snake bite to be 13.5%. In this study, the requirement of RRT was 45.3% and the mortality observed was 22.5%. According to this study, the risk factors for development of AKI were cellulitis and regional lymphadenopathy, while the predictors of poor outcome were hypotension and bleeding.

Sweni et al134 in their study from Chennai reported a prevalence of AKI in snake bite of 7%.

Jayakumar et al132 in their study reported that 7.8% of cases of AKI were due to snake bite. The requirement of RRT in this study was 94.2%. As the study was done in a tertiary referral centre, most patients were referred late with renal failure. They reported a mortality of 27.5%.

Sepsis is the emerging cause of AKI. It accounted for 10.7% of cases of AKI in our study. AKI due to sepsis were common in the 4th (41.6%) and 5th decades (25%).

AKIN stage distribution of sepsis induced AKI: Stage 1, 2(16.7%); Stage 2, 3(25%); Stage 3, 7 (58.3%).

Sepsis induced AKI had the highest in-hospital mortality of 58.3%, which is similar to data from other Indian centres. It may be due to an association with co-morbid illnesses (Diabetes), and higher incidence of multi organ dysfunction syndrome in these patients. Thus sepsis- induced AKI was among the worst prognostic group.

Worldwide, the incidence of sepsis related AKI is increasing. AKI represents an independent risk factor for mortality in these patients. The requirement of dialysis in our study was 41.7%.

Jayakumar et al132 reported the incidence of sepsis related AKI to be 8.8%. The requirement of RRT was 78.5% and mortality was 56.1%.

Kaul et al129 reported a mortality of 46.1% and need for dialysis of 92.3% for sepsis related AKI.

Tropical acute febrile illnesses are a common cause of AKI in the developing countries. In Southern India, the common tropical acute febrile illness among hospitalized patients included malaria, typhoid, scrub typhus, dengue, leptospirosis, spotted fever and others. In our study, tropical acute febrile illnesses accounted for 7.14% of AKI. Out of 8 patients, 6 (5.3%) were due to leptospirosis. For the remaining 2 patients (1.7%) the aetiology of fever could not be ascertained.

AKIN stage distribution of tropical acute febrile illness induced AKI: Stage 1, 1(12.5%); Stage 2, 1(12.5%); Stage 3, 6 (75%).

Two patients (25%) with leptospirosis required dialysis, both had in-hospital mortality (25%).

Basu et al135 in a study from Vellore reported a 3.9 % incidence of AKI in leptospirosis. There was no mortality or requirement for dialysis. The incidence of leptospirosis in this study was lower than that observed in centres with humid, marshy environment and higher rainfall.136

Jayakumar et al132 reported a 7.5% incidence of AKI in leptospirosis. 53.5% of patients required dialysis and mortality was 9.5%.

Kaul et al129 reported an incidence of 6.25% of leptospirosis related AKI.

There has been a dramatic reduction in the incidence of leptospiral AKI. Leptospirosis was once the most common cause of AKI in this part of India130. Whether this reduced incidence is real or due to greater awareness, better diagnostic facilities, and/or the widespread use of empirical penicillin is not clear.

In the last decade, malaria has returned to many places from where it was said to have been eradicated. India contributes 80% of all cases of malaria in Southeast Asia. Although falciparum infection remains the most common cause of complicated malaria, various Indian investigators have documented the increased incidence of complicated malaria in vivax infections. AKI due to falciparum malaria has been reported mostly from Southeast Asia and Africa. Malarial AKI has not been reported in the current study.

No cases were also reported by Muthusethupathi et al130.

Jayakumar et al132 reported a 4.4% incidence of AKI, mostly (93.8%) due to plasmodium falciparum. Plasmodium vivax was also observed in 6.2% of malarial AKI. Dialysis was required in 77.5% and mortality was 26.5%.

Kaul et al129 reported an incidence of malarial AKI of 18.8%. Need for dialysis was 88.6% and mortality was 20%.

Basu et al135 in their study reported that falciparum malaria (pure and mixed, respectively) had the highest incidence of AKI (63.2% and 54.2%). Mortality was much lower (13.2% and 4.2%) compared with the other acute febrile illnesses. Requirement of RRT was 23.7% and 16.7% respectively. Probably due to early diagnosis and effective treatment, the mortality was much lower. All patients who died had AKI, making it an important risk factor for mortality.

In our study, 4 patients (3.6%) had acute glomerulonephritis. AKI due to AGN is most common in the 3rd decade (75%).

AKIN stage distribution of AGN induced AKI: Stage 1, 2(50%); Stage 2, 1(25%); Stage 3, 1 (25%).

One patient was treated with HD (25%). All patients recovered.

Jayakumar et al132 reported the incidence of AGN related AKI to be 9.3%. The requirement of RRT was 84.6% and mortality was 21.1%. Crescentic glomerulonephritis, followed by post-infectious proliferative glomerulonephritis, SLE, and IgA nephropathy (in order of frequency), accounted for the cases.

Kaul et al129 reported an incidence of AGN related AKI of 6.45%. Need for dialysis was 66.7% and mortality was 25%.

Drugs are a common cause of AKI. In our study only patient (0.9%) had NSAID induced AKI. He was managed conservatively.

Jayakumar et al132 reported that drugs were the second most common cause of AKI. Unknown analgesic combinations were the most common reason for admission due to drug-induced AKI, followed by Rifampicin and NSAIDS. Rifampicin-induced AKI was noted to occur frequently in patients who received intermittent therapy.

Kaul et al129 reported an incidence of drug induced AKI of 6.45%. Need for dialysis was 77.8% and mortality was 22.2%.

AKI due to Super Vasmol poisoning contributed 2.7% and that due to copper sulphate poisoning contributed 1.8% in our study. All cases of Super Vasmol poisoning occurred in females. Suicidal tendency is more common in females than in males.

Among 3 patients with Super Vasmol poisoning, one required dialysis in the form of HD (33.3%). The patient however had in-hospital mortality (33.3%). Among 2 patients with copper sulphate poisoning, both were treated conservatively, however one patient had in-hospital

mortality. There were no cases of AKI due to rat killer poison in our study.

Super Vasmol is now emerging as a major cause of suicidal poisoning in India.137Sahay et al138 reported that 0.6% of all AKI in their study was due to Super Vasmol.

Sweni et al134 reported that amongst the chemical poisons, copper sulphate (10%) and rat killer (1.4%) were the commonest causes of AKI.

Jayakumar et al132 in their study reported an incidence of 4.3% for copper sulphate induced AKI with a requirement of dialysis of 64.5% and mortality of 35.4%.

No cases of Super Vasmol poisoning were reported by Jayakumar et al132 and Kaul et al.129

2 patients (1.8%) with AKI in our study were due to pigment nephropathy. Both patients required RRT in the form of HD. Both patients recovered.

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